Chapter 5

Preparation

In this chapter you will complete your Exposure Inventory Worksheet: a detailed plan for how to stop safety behaviors and systematically expose yourself to what you’ve been avoiding. Your inventory builds on all the work you have done to this point: listing your feared situations and experiences, examining your safety behaviors in detail, and putting numerical values on the negative distress you feel and the positive values by which you want to live your life.

Planning

To further refine your inventory you will add a plan to stop safety behaviors, as well as “predicted outcomes,” and “percent probability” to each of your feared situations. On the following worksheet, write down one of your feared situations, your associated safety behaviors, the subjective units of distress (SUDS), and the relative value ratings you made in the previous chapters. (This worksheet is available to download at http://www.newharbinger.com/34749.)

Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability

In the third column, make a plan for stopping your safety behaviors and exposing yourself to what you have been avoiding. There are two ways to do this: the cold turkey plan and the gradual plan.

Cold Turkey Plan

In this plan, you immediately stop the distraction, reassurance seeking, procrastination, and so on—all the things you have been doing to soften or postpone facing your anxiety. And you immediately do the things you have been avoiding doing. You dive right into the cold water of the feared situation.

Remember Eileen, the equestrian who became anxious about riding her horse? She made a cold turkey plan to handle many of her feared situations:

Eileen’s Exposure Inventory Worksheet, Cold Turkey Plan

Feared situation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Cantering	Holding saddle horn	Hold reins, don’t touch saddle horn	60	3
Visiting horse	Procrastinate, say “Good boy!” constantly	Visit twice a week, no “Good boy”	30	3
Remembering the fall	Distraction	Plan on four 20-minute sessions recalling accident and hospital stay	50	4
Talking about the fall	Avoiding any mention of it	Get Mom to listen to the whole story—30 minutes	45	4
Walking horse in corral	Seeking reassurance from instructor	Send instructor out of earshot	35	3
Thinking about difficult trails	Distracting with iPhone	Think about them for 15 minutes without distraction	45	5

Gradual Plan

The second way to discontinue safety behaviors is to reduce them more gradually. You can create a hierarchy that goes from full use of the safety behavior, to partial use, and incrementally to no use. The trick is to devise two to five steps that can cushion the shock of a cold-turkey plunge into zero safety behaviors. Plan a gradual lessening of safety behaviors if you sense that your anxiety will be too overwhelming with a cold turkey approach. Of course, there is a downside to gradual plans: they take a lot longer.

Here’s how Eileen made gradual plans for riding the Meadow Loop Trail and overcoming panic sensations on steep trails:

Eileen’s Exposure Inventory Worksheet, Gradual Plan

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Riding Meadow Loop Trail	Procrastinating, avoiding, or riding only with instructor	Ride with instructor leading the way Ride with instructor behind me Ride alone with instructor on speed dial Ride alone	75	4
Panicky feeling when horse thrusts up on steep trails	Avoiding, postponing, saying maybe I’ll ride with instructor	Stand at foot of grade and watch instructor ride it Ride the grade with instructor watching Ride the grade with instructor on speed dial Ride alone	100	5

Here are some other ways to gradually eliminate other typical safety behaviors:

• For overpreparation, cutting preparation time in increments until it reaches an appropriate level
• Waiting longer and longer periods to seek reassurance
• Cutting time spent in distraction, or changing the types of distraction
• Limiting procrastination time by setting a deadline or completing the exposure in increments
• For avoidance, doing part but not all of an exposure, then working up to the full exposure
• Checking less and less frequently
• For perfectionism, making deliberate mistakes—first one, then two, then three
• Reducing time spent doing a ritual until it reaches nothing; cutting the number of words in a ritual prayer or coping thought; using the ritual half the time, then a quarter of the time, and so on
• For list making, creating shorter lists and setting a limit for how much time you will spend on lists.
• Reducing the quantity, frequency, and/or potency of drug and alcohol consumption.

Predicting Worst-Case Outcomes

The false alarms that have plagued you and driven your struggle with anxiety can’t be overcome with reasoning. You can’t argue away your fears. You’ve no doubt tried—or others have—and the alarm reactions just keep happening. When it comes to anxiety, and the belief that certain things or situations are dangerous, you can’t think your way out of it. Only real, disconfirming experiences can change deeply held beliefs. This is true for all of us—we literally have to be shown that our beliefs about danger aren’t true before they can change. We have to experience the thing we’ve feared and have something other than what we expected happen.

The mismatch between the harmful thing you expect and actual outcomes is critical to new learning. And the more your expectation is contradicted by direct experience, the more powerfully your old beliefs about danger will be disconfirmed. Overcoming false alarms, and all the avoidance they generate, involves predicting that a particular aversive outcome will occur (from an exposure) and then carefully comparing actual outcomes to the prediction.

In the sixth column of your Exposure Inventory Worksheet, for each of your plans, you need to make a prediction: what are you most afraid will happen if you follow your plan and stop your safety behavior? This prediction should be expressed as observable behavior—yours or others’—as opposed to your feelings and internal experiences. For example, individuals who fear elevators might predict that the doors will close and they will be stuck between floors. Or that the cable will break and the elevator will start to drop. Or that they will have a heart attack while riding the elevator. Notice that the prediction doesn’t include how the individual will feel, but rather focuses on a worst-case scenario of what is expected to happen.

While there is no point predicting that you’ll feel anxiety—because you will—you can predict your own behavioral responses. Returning to the elevator example, a behavioral prediction might look like this: “I’ll be so overwhelmed, I’ll push the button for the next floor, get off, take the stairs down, and go home.” You can also predict other people’s behavior in response to your tests. For example, a socially anxious woman, who is afraid of asking questions, predicted the following: “When I ask department store clerks about the quality and durability of a particular item, they’ll get a contemptuous look, say (in so many words) my question is ridiculous, and walk away from me.” Notice the prediction doesn’t center on how the clerk feels or what the clerk thinks. There’s no way to observe and know that. The prediction is based entirely on outcomes you can see—they either happen or they don’t.

Go back and write in your worst fears and exactly what will happen if they come true.

Percent Probability

The next step in the prediction process is to assess how likely it is that the feared outcome will take place. For example, you might assess that there is “an 80 percent chance that standing next to a dog will result in getting bit.” Or that there is “a 70 percent chance I’ll cut myself or someone else if I use a chopping knife.” Or that there is “a 90 percent chance I’ll be so scared I’ll have to get off the subway before reaching my stop.” For each of your worst-case outcomes, note the percent probability in the last column.

Notice that the percent probability isn’t based on actual odds, but on what your fear tells you. For example, you may know rationally that millions of people use knives every day without mishap. But your assessment of the probability of injury should be based on your feeling of danger and your subjective belief about likely outcomes if you use a knife.

Completing Your List of Feared Situations

Continue listing all your feared situations on your inventory, with safety behaviors, plans, and so on, until all columns are filled in. Take your time and do a thorough job. Remember, the basic solution to anxiety is simple: avoid what you usually do, and do what you usually avoid. But the implementation can be complex, layered, subtle, and time-consuming.

Examples

To help you figure out how to make better exposure plans and outcome predictions, the rest of this chapter consists of detailed examples of other people’s inventories. There is at least one example for each of the six anxiety disorders. Some disorders have more than one example, to show the widest possible range of options in filling out an exposure inventory.

Look through all of the examples, even if you don’t suffer from the particular type of anxiety exemplified. You will learn different ways to structure your inventory to create a list of doable exposure experiences. Notice how others:

• combine two mildly feared situations to make one more scary situation
• break a very scary situation down into several less scary situations
• make a plan gradual by altering the distance in time or space to a feared object
• include visualizations of past experiences or imagined scenes, which tends to increase expectations that the predicted worst-case outcomes will happen
• keep predicted outcomes behavioral and observable, not feeling-based
• set higher percent probabilities based on subjective fear, not actuarial data

Generalized Anxiety Disorder (GAD)—Stephan’s Rumination

Stephan struggled with a harsh “worry voice” that plagued him with frequent rumination about his health, his job, money, and crime. Notice that his feared situations all have the excessive worry component so typical of generalized anxiety disorder. Note that Stephan highly valued learning to face medical fears and getting free of constant worry about his symptoms.

Stephan’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Thinking doctor is wrong and stomach pain is not just gas	Lots of online medical research	Just stop cold turkey	85	5	Undetected stomach cancer will make me keep getting sicker.	65%
Worrying I’ll lose everything when stock market goes down	Constantly check Dow and S&P, call broker for reassurance	Check twice today, once tomorrow, skip a day, once more, then stop cold. Call broker only once a quarter.	75	4	Market will tank soon and I’ll be wiped out, homeless.	50%
Assuming if I buy a new Buick it will be a lemon	Rechecking Consumer Reports, procrastinating, frequent test drives, reassurance seeking with friends	Drive each of five models once, then decide	60	2	I’ll pay high end for a car and just keep pouring money down a bottomless pit.	70%

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Thinking about recent mass shooting as I’m going to a concert—I’ll be killed	Seeking reassurance from friends, checking news stories about terrorist activities	No more reassurance conversations, stay off news sites	65	3	Concert will be targeted by a deranged shooter and I’ll get shot, or at least trampled in the stampede.	60%
Afraid of getting fired when boss asks for a meeting	Ask colleagues for reassurance	Stop talking to colleagues about boss and performance reviews	90	4	I’ll lose my job, then my house, then my wife and kids.	90%
Fearing heart attack when heart rate goes up at gym	Constantly taking pulse, online medical research at home	Stop cold turkey	70	5	I’ll collapse on the treadmill with a heart attack.	70%

Social Anxiety—Antonio’s Fear of Socializing

Antonio is lonely. His last girlfriend was six years ago in college, someone who asked him out. His fear of being judged or rejected has kept him from:

• talking to female coworkers
• talking to fellow commuters
• going to parties or work gatherings
• going to Meetup groups
• putting up a profile for online dating
• asking someone on a date
• going to political meetings or events (Antonio is interested in conservation, ecology, and the Green Movement)

Antonio’s exposure inventory for social anxiety is typical in that it involves two types of exposure:

1. Situations that will induce him to speak with others, particularly people to whom he’s attracted.
2. Visualizations of worst-case scenarios in which his attempts at conversation are met with scorn and rejection.

Notice that Antonio highly values any exposures involving contact with Irene, someone he likes at work.

Antonio’s Exposure Inventory Worksheet

Fearedsituation	Safety behaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Talking to others	Avoid it, keep quiet, don’t go to parties and other events	Say “hello” to Irene at her desk	50	5	She’ll shrug, avoid eye contact, and look away	60
		Put up online dating profile	60	3	Too scary, won’t finish it and hit “submit”	80
		Go to “Save the Earth” Meetup group	65	4	No one will talk to me	70
		Start a conversation with Irene about her vacation	70	5	She’ll look away and ignore me	70
		Go to singles bar—30 min.	70	2	No one will talk to me	85
		Go to after-hours office party—30 min.	75	2	I won’t talk to anyone, they won’t talk to me	80
		Respond via e-mail to 5 interesting profiles	75	3	No one will respond to me	90

Fearedsituation	Safety behaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Talking to others	Avoid it, keep quiet, don’t go to parties and other events	Go to party at my sister’s house	80	2	I won’t say a word to anyone, no one will talk to me	75
		Make a small (hopefully funny) remark to someone on train	80	2	They’ll look disgusted, refuse to speak to me	80
		Go on Sierra Club Singles hike and talk to 2 people	90	3	They’ll look offended, move away from me	95
Being rejected	Avoid	Visualize talking to woman on train who looks disgusted and moves away	55	1	Have to stop, too painful	60
Combos	Avoid	Visualize being scorned + conversation with Irene	70	1	She’ll say she’s busy and look away	95
		Visualize being scorned + go to singles bar—no alcohol	95	3	People will avoid me, they’ll move away when I speak to them	100

By now you should have a pretty long Exposure Inventory Worksheet, probably rewritten a few times as you revise your plans for stopping safety behaviors and exposing yourself to your feared situations. In the next chapter you will finally get a chance to put your inventory to use, and start solving your anxiety problems with positive actions.

Obsessive-Compulsive Disorder (OCD)—Mary’s Fear of Doing Harm

Mary feared harming her two-year-old daughter or her husband with a sharp implement such as a knife, serving fork, scissors, or needle. She reached the point where she was afraid to cook or sew, particularly if her daughter or husband were anywhere near. Her exposure inventory included holding and then using sharp implements, as well as visualizing accidentally cutting her daughter with a knife. Notice that items involving shared activities with her daughter are highly valued.

Mary’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Picking up paring knife or carving knife, especially near husband or daughter	Avoid it, wait until they’re gone	Holding carving knife—1 min.	60	2	Drop knife or cut myself	70
		Holding carving knife—3 min.	70	2	Drop knife or cut myself	80
		Holding paring knife—1 min., husband across kitchen	70	2	Cut husband	60
		Holding paring knife—3 min., daughter across kitchen	80	2	Cut daughter	75
		Holding carving knife and fork, daughter across kitchen	80	2	Cut or stab daughter	75
		Holding carving knife and fork, daughter near cutting board	90	2	Cut or stab daughter	85
Chopping	Avoid it, buy precut veggies	Chopping 5 carrots, salad, daughter across kitchen	85	3	Cut daughter	80

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Chopping	Avoid it, buy precut veggies	Chopping 10 apples for pie, daughter near cutting board	95	4	Cut daughter	95
Sewing with needles, cutting cloth with scissors	Only do it alone or not at all	Cutting cloth, living room, daughter across room	70	4	Cut daughter	70
		Cutting cloth, living room, daughter near me	85	5	Cut daughter	90
		Hand sewing her costume, daughter across room	65	4	Poke daughter with needle	70
		Hand sewing her costume, daughter near me	75	4	Poke daughter with needle	80
Thinking about cutting daughter	Distraction with TV, Internet,	Visualize daughter cut by knife	70	1	I’ll have to stop visualizing, distract myself	80
Combos	Avoid	Visualize daughter cut and sewing with her near	95	5	Poke daughter with needle	90
		Visualize daughter cut and chopping with her near	100	3	Cut daughter	100

Obsessive-Compulsive Disorder (OCD)—Annalea’s Fear of Contamination

Annalea had struggled with a fear of germs since her college roommate contracted mononucleosis and had to drop out of school. She became increasingly vigilant in looking out for any possibility of contamination. She avoided touching doorknobs, railings, toilets, floors, chair seats, paper money, and other people—particularly their hands. When Annalea touched something she believed to be contaminated, she suffered extreme anxiety until she washed or showered. Washing rituals could last up to several hours, and on bad days Annalea spent much of her time compulsively “de-germing” herself. She strongly valued her relationships, as you’ll see in exposure items involving family and friends.

Annalea’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Touching doorknobs	Avoiding, washing	Touching inside doorknob for 10 seconds, washing only 3 min. after toilet and before meals, no other washing	40	1	Sick by bedtime	60
		Touching outside doorknob for 10 sec., washing only 2 min. after toilet, before meals, no other washing	60	3	Sick by bedtime	80
Being near sick people	Avoiding, washing	Visualize seeing roommate in hospital	40	4	Can’t stand it, have to stop	60
Touching floor	Avoiding, washing	Both hands on living room floor for 30 sec., washing 2 min. only after toilet, before meals	65	2	Sick by bedtime	70
Touching other people	Avoidance	Shaking hands with friends at a political meeting, washing 1 min. after toilet, before meals	80	4	Sick by bedtime	95

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Touching other people	Avoidance	Hugging mother, 1 min., washing as above	45	5	Sick by bedtime	60
		Taking mother’s arm to help her walk, washing as above	60	5	Sick by bedtime	70
Touching money	Avoiding, washing	Counting money in wallet, washing as above	70	3	Sick by bedtime	75
		Counting money from ATM, washing as above	80	3	Sick by bedtime	85
Touching toilet	Avoiding, washing	Lower toilet seat with my hand, washing as above	100	2	Sick by bedtime	100
Touching chairs and railings	Avoiding, washing	Hands on armchair, washing only 30 sec.	70	2	Sick by bedtime	60
		Hands on my mother’s armchair, washing 30 sec.	80	3	Sick by bedtime	65
		Hands on park bench seat, washing 30 sec.	75	1	Sick by bedtime	80
		Hands on store stair railing, washing 30 sec.	70	2	Sick by bedtime	85

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Touching floor	Avoiding, washing	Both hands on bathroom floor—30 sec., washing 30 sec.	100	3	Sick by bedtime	95
Near sick people, touching sick people	Avoiding, washing	Visualize roommate in hospital + shaking hands with friends, washing 30 sec.	90	4	Sick by bedtime	100
		Visualize roommate in hospital + counting money from ATM, washing 30 sec.	85	3	Sick by bedtime	90
Touching doorknobs and money	Avoiding, washing	Hand on store doorknob + count money, washing 30 sec.	95	3	Sick by bedtime	95

This example showed Annalea’s inventory for exposing herself to her contamination fears and discontinuing her safety behavior of prolonged hand washing. While not fully shown in her inventory, she also systematically reduced the time she spent showering. In the end, she tapered down to showering once a day for ten minutes and washing her hands for only thirty seconds before each meal and after using the bathroom.

Obsessive-Compulsive Disorder (OCD)—Morgan’s Forbidden Thoughts

Morgan, the son of missionaries, lost his girlfriend in a car accident when she was only thirty-one. At the funeral he had the sudden thought, I hate God. The thought was so disturbing and unacceptable that he tried to banish it from his mind. But the more he tried to avoid the thought, the more frequently it appeared. As a way of undoing or neutralizing the thought, he whispered, “Sorry, sorry, sorry,” each time it occurred.

Morgan’s inventory first worked on stopping his ritual “Sorry, sorry, sorry” safety behavior, then concentrated on tolerating the I hate God phrase as a thought alone, as a thought in certain situations, when said out loud, and when written down.

Morgan’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Thinking my I hate God thought	Ritual: whispering “Sorry, sorry, sorry.” Trying to avoid the thought	Shorten to two sorries for a day, then one sorry for the next day, then no sorries thereafter	80	3	I won’t be able to stop. If I do stop, God will physically strike me down.	75
		Think my thought once alone	55	1	Physically struck down	60
		Think it 10 times	70	1	Physically struck down	65
		Think it 50 times	85	1	Physically struck down	70
		Think it while talking to clients	70	3	They’ll know, and will cancel their contract	90
		Think it while with parents	90	3	They’ll read my mind	60
		Think it in church	100	1	Physically struck down	100

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Writing down the thought	“Sorry, sorry.”	Write it once	65	3	Physically struck down	60
		Look at it and read it for 5 minutes	90	3	Physically struck down	60
		Write it 10 times	70	3	Physically struck down	70
		Write it 50 times	90	3	Physically struck down	80
		Write it on big sheet of sketch paper	80	2	Physically struck down	85
Saying the thought out loud	“Sorry, sorry.”	Say it once while alone in the car	70	2	Physically struck down	80
		Tell my friend Alex about my thought	95	3	He’ll reject me	95

Panic Disorder—Sergio’s Fear of Travel

Sergio had his first panic attack in a hotel, following a turbulent and stressful plane flight. The physical symptoms included feeling dizzy/light-headed and flushed, rapid heart rate, a sense that he couldn’t get enough air, and weakness in his legs. Subsequent panic attacks were at first rare, occurring only when he traveled far from home. As time went by, they began to happen on public transportation, in crowded places, on long drives, and when caught in traffic, always preceded by one or more of his physical symptoms. If you look at the values column in Sergio’s inventory below, you’ll see that his fear of panic attacks kept him from enjoying activities he valued very highly, such as movies, eating out, and spending time with friends.

Note that Sergio’s inventory contains situational, interoceptive, and imagery-based exposures. His panic disorder was typical in that what he dreaded was not so much certain situations, but rather the interoceptive physical sensations of panic that he might feel in those situations. For exposure to work in treating panic disorder, it helps to design safe, controllable experiences that will reproduce similar physical sensations. Sergio recreated the interoceptive experiences as follows:

Panic symptom	Interoceptive equivalent
Rapid heart rate	Running in place
Flushed/hot feeling	Running in place with heavy coat
Dizziness/light-headedness	Very rapid breathing
Difficulty breathing	Breathing through a straw
Leg weakness	Holding a “half squat” until legs feel weak/shaky

Sergio’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Driving more than a few miles	Avoidance: stay home, get rides	Drive to San Rafael—30 min.	45	2	Panic, have to stop	60
		Drive to Napa—60 min.	55	2	Panic, have to stop	70
		Drive to Clear Lake—2 hrs.	70	5	Panic, have to stop	75
Thinking about my first panic	Distraction, drinking, Internet	Visualize 1st panic— 2 min., then 5 min., no distraction or numbing	45	1	Can’t stand it, have to stop	60
Taking public transportation	Avoidance	BART train to Oakland	50	1	Panic, have to get off	60
		BART train to S.F.	70	3	Panic, have to get off	60
		Bus to Sacramento	80	4	Panic, have to get off	75
		Bus to Reno	90	5	Panic, have to get off	95

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Freeway driving	Never do it anymore, get rides or stay home	Freeway—4 exits—4 p.m.	50	2	Panic, have to stop	65
		Freeway—2 exits—5 p.m.	70	2	Panic, have to stop	70
Combo situations	All of above	Visualize 1st panic + drive	60	2	Panic, have to stop	80
		Visualize 1st panic + BART	70	1	Panic, have to get off	80
		Visualize 1st panic + freeway	70	2	Panic, have to stop	80
Going to the movies	Stay home, watch TV	Go to popular movie	65	4	Panic, have to leave	60
Eating out	Avoid	Go to popular restaurant	75	5	Panic, have to leave	80

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Interoceptive panic sensations: being out of breath, hot, rapid heart rate, shaky muscles	Stop whatever I’m doing that seems to be causing it	Running in place—1 min.	75	2	Panic, have to stop	60
		Running in place—2 min.	85	2	Panic, have to stop	65
		Running + heavy coat—2 min.	95	2	Panic, have to stop	80
		Running, then driving	90	3	Panic, have to stop	90
		Very rapid breathing—1 min.	70	1	Panic, have to stop	80
		Very rapid breathing, then driving	85	2	Panic, have to stop	100
		Breathing through straw—1 min.	60	1	Panic, have to stop	65
		Half squat—2 min.	55	2	Panic, have to stop	65

For even more details on designing interoceptive exposures, see Appendix IV at the end of this book.

Specific Phobia—Sophia’s Fear of Bees

Specific phobias can arise in connection to virtually any object or situation. Common phobias include insects, animals, heights, closed spaces, driving, injections and other medical procedures, public speaking, water, and many others. Developing items for a phobia inventory typically involves manipulating:

• distance from the feared object or situation, where the closer you get, the more you expect catastrophe
• level of threat such as how much time is spent near the feared object or in the feared situation. Or how dangerous the exposure feels—is it a picture of a snake or a real snake? How big is the snake? Is it in a cage? Will you touch it?
• catastrophic images of worst-case outcomes such as reading about someone who was bitten by a snake or imagining it.

The following inventory documents the exposure plan for Sophia, a professional gardener who was afraid of bees. She cared deeply about her job, as you’ll see in her value ratings.

Sophia’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Reading article about bees	Avoidance	Read article about someone attacked by bees	85	2	Too scared, put magazine down	90
		Hold a picture of a bee	40	1	Will drop it	60
		Look at picture of someone with multiple bee stings	80	2	Too scared, put picture down	90
Videos of bees	Avoidance	Looking at a video of bees on computer	50	1	Will turn it off	60
		Listening to recording of many bees buzzing	45	1	Will turn it off	65
Flower gardens with bees	Avoidance	Stand halfway to my dahlias (lots of bees) for 1 min.	65	3	Will be stung	60
		Stand halfway to my dahlias for 3 min.	75	3	Multiple stings	70

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Flower gardens with bees	Avoidance	Stand next to dahlias for 30 sec.	80	3	Multiple stings	80
		Stand next to dahlias for 2 min.	90	3	Multiple stings	90
		Stand next to dahlias for 5 min.	95	3	Multiple stings	95
		Visit flower beds in Ms. Latham’s yard	80	5	Will be stung	75
		Prune back a rosebush at Ms. Druery’s	70	5	Multiple stings	75
Combos	Avoidance	Stand next to dahlias while reading bee attack article	100	3	Multiple stings	100
		Read bee attack article right before hoeing Ms. Latham’s flower bed	90	5	Multiple stings	95

Specific Phobia—Stan’s Fear of Needles

And here is another specific phobia inventory, this one by Stan, a newly diagnosed diabetic who was afraid of needles. As you can see from his value ratings, he had a strong value about staying healthy, which required him to learn to administer his own insulin injections.

Stan’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Being around injection stuff—vials, syringes, etc.	Avoid, distract, ask for reassurance	Sit in doctor’s waiting room	55	2	Leave immediately	60
		Look at picture of syringe	45	2	Stop, put it down	60
		Watch a video of someone getting a shot	50	2	Can’t stand it, turn it off	90
		Watch nurse demonstrate injecting an orange	80	4	Leave immediately	80
		Smell alcohol on cotton ball	55	1	Stop immediately	60

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Receiving an injection	Avoid, distract with chatter, look away	Visualize getting a painful shot	70	2	Cut off the images	65
		Visualize getting a shot, screaming and fainting	70	2	Cut off the images	70
		Nurse gives me an insulin shot in leg, watch it happen, don’t look away	90	5	Scream, faint	85
Giving myself an insulin injection	Avoidance	Stick my finger with a pin	80	2	Can’t do it	90
		Hold a syringe filled with saline	75	3	Stop, leave	90
		Give myself insulin shot in leg	100	5	Can’t do it, faint	95

Post-Traumatic Stress Disorder (PTSD)—Laura’s Sexual Assault

Laura was the victim of a nighttime break-in during which she was slapped awake by her assailant and sexually assaulted in her bed. Since the attack, she’s suffered flashbacks, surges of anxiety, and sadness, and she has an overwhelming fear of being alone at night.

Recovery from PTSD symptoms involves two very different kinds of exposure:

1. Imagery exposure that involves visualizing the event in detail. This can often be accomplished by making a recording lasting fifteen to thirty minutes describing each minute step of the trauma, including as much as possible about what happened emotionally, physically, and cognitively during the event.
2. Situational exposure to current fears that have been triggered by the trauma. For Laura, who must either spend the night at the home of friends or persuade friends to stay with her, the fear of being alone at night has become a serious problem. As you’ll see, many items in her inventory are situational exposures designed to change the belief that she’ll be attacked if she spends the night alone.

Laura has strong values about facing the pain in her life and maintaining her independence, as you’ll see in her inventory.

Laura’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Remembering the attack	Avoid, distract, mental rituals	Record the story of the attack on my phone—15 minutes long	85	5	Can’t stand it, will have to stop	95
		Listen to 5 minutes of the recording on my phone, during which I describe everything that happened during the attack	80	5	Can’t stand it, will have to stop	80
		Listen to 10 minutes of the recording	75	5	Can’t stand it, will have to stop	75
		Listen to all 15 minutes of the recording	70	5	Can’t stand it, will have to stop	75

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Spending the night alone	Avoid, stay at friends’ houses	Stay alone in hotel—1 night	70	4	Will be attacked	60
		Stay the night at a friend’s house with no one there	70	3	Will be attacked	80
		Stay alone in hotel—2 nights	75	5	Will be attacked	70
		Listen to recording of attack + spend night in hotel	80	5	Will be attacked	75
		Stay alone at home until 10:00 p.m.	80	4	Will be attacked	70
		Listen to recording of attack + stay alone at home until midnight	85	5	Will be attacked	80
		Stay alone at home until midnight, then check into hotel	90	4	Will be attacked	80
		Spend night alone at home	100	5	Will be attacked	95

Post-Traumatic Stress Disorder (PTSD)—Aaron’s Commuter Train Derailment

Three years ago, Aaron was in the second car of a high-speed commuter train when it left the tracks and plowed into a warehouse. Passengers flew through the air and there were four dead in Aaron’s car. Survivors were trapped for more than an hour while rescuers and paramedics tried to reach them. While waiting for help, Aaron was in great pain with a broken leg and ribs.

As noted in Laura’s case, PTSD must be treated with both imagery exposure (a recorded description of the event) and situational exposure for current, associated fears. In Aaron’s case, he retained a morbid fear of trains, planes, and buses, and had been forced to quit his job because it required significant travel. Note that his valued exposures all involve increasing his ability to travel.

Aaron’s Exposure Inventory Worksheet

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Remembering the derailment	Avoiding, taking tranquilizers, drinking too much, distraction	Making an 18-minute recording of the accident—what I saw, heard, smelled, thought, and felt emotionally and physically	90	1	Have to quit	80
		Listen to recording once on day 1—no drinking, drugs, or distraction	85	1	Have to quit	80
		Listen to recording twice on day 2—no d, d, or d	80	1	Have to quit	80
		Listen to recording 3 times on day 3—no d, d, or d	65	1	Have to quit	70
		Listen to recording 4 times on day 4 —no d, d, or d	60	1	Have to quit	70
		Listen to recording 5 times on day 5—no d, d, or d	50	1	Have to quit	65
		Read article about the derailment—no d, d, or d	50	1	Have to quit	65

Fearedsituation	Safetybehaviors	Plan to stop safety behavior and to expose	SUDS 1–100	Value 1–5	Predicted worst-case outcome	Percent probability
Taking public transportation	Avoiding, distraction, tranquilizers	Trolley to zoo	45	2	Panic, get off	60
		Bus to Stonestown	45	2	Panic, get off	60
		Bus to Berkeley art museum	55	3	Panic, get off	75
		Train to Millbrae	70	2	Panic, get off, crash	80
		Train to San Jose	80	3	Panic, get off, crash	90
		Plane to LA to visit brother	55	4	Panic, want off, throw up, crash	60
Combos	Avoiding, distraction, tranquilizers	Listen to recording + train to Millbrae	85	2	Crash	75
		Listen to recording + train to San Jose	90	3	Crash	80
		Read about crash + train/bus to Yosemite	95	4	Crash	95